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Academic Radiology May 2024The dogma is that normal parathyroid glands (PTGs) are not visible on ultrasound (US). Recently, several studies have shown that PTGs present these US features: ovoid...
RATIONALE AND OBJECTIVES
The dogma is that normal parathyroid glands (PTGs) are not visible on ultrasound (US). Recently, several studies have shown that PTGs present these US features: ovoid structure, homogeneous and hyperechoic. The primary objective was to assess the detection rate, standard size and locations of normal PTGs in a population of patients consulting for thyroid US exam. The secondary objective was to determine if the presence of a goiter or a thyroiditis could modify the visualization of normal PTGs.
METHOD
Single-center prospective study on 192 patients based on the typical US appearance previously described to identify one or more PTGs.
RESULTS
One or more PTGs were visualized in 75% of patients (144/192). They were visualized preferentially at the lower pole of the thyroid gland and in the infra-thyroid region (66%). The mean (± SD) size of normal PTGs was 5.68 mm (± 1,42 mm)×4.05 mm (± 1,03 mm)×2,68 mm (± 0,61 mm) and mean volume was 33.3 mm3 (± 17.75 mm3). The presence of a goiter made the search for PTGs more difficult whereas the presence of thyroiditis facilitated it.
CONCLUSION
The US detection rate of PTGs is high (75%). The identification of PTGs could be particularly useful in the preoperative assessment before total thyroidectomy or parathyroid surgery. It could reduce the risk of postoperative hypoparathyroidism and improve the accuracy of postoperative US surveillance of thyroid cancer. Better knowledge of the usual anatomical location of normal PTGs could also enable better detection of abnormal glands.
PubMed: 38777720
DOI: 10.1016/j.acra.2024.03.026 -
ACS Pharmacology & Translational Science May 2024The calcium sensing receptor (CaSR) is a ubiquitously expressed G-protein coupled receptor (GPCR) that regulates extracellular calcium signals the parathyroid glands....
The calcium sensing receptor (CaSR) is a ubiquitously expressed G-protein coupled receptor (GPCR) that regulates extracellular calcium signals the parathyroid glands. CaSR has recently also been implicated in noncalcitropic pathophysiologies like asthma, gut inflammation, and cancer. To date, molecular tools that enable the bioimaging of CaSR in tissues are lacking. Based on analyses of available structure-activity relationship data on CaSR ligands, we designed and prepared silicon-rhodamine (SiR) conjugates of the clinically approved drug evocalcet. The new probes EvoSiR4 and EvoSiR6, with differing linker lengths at the evocalcet carboxyl end, both showed a 6-fold and 3-fold increase in potency toward CaSR (EC < 45 nM) compared to evocalcet and the evocalcet-linker conjugate, respectively, in an FLIPR-based cellular functional assay. The specificity of the EvoSiR probes toward CaSR binding and the impact of albumin was evaluated in live cell experiments. Both probes showed strong albumin binding, which facilitated the clearance of nonspecific binding interactions. Accordingly, in zebrafish embryos, EvoSiR4 specifically labeled the high CaSR expressing neuromasts of the lateral line . EvoSiR4 was also assessed in human parathyroid tissues , showing a specific absolute CaSR-associated fluorescence compared to that of parathyroid autofluorescence. In summary, functionalization of evocalcet by SiR led to the preparation of potent and specific fluorescent CaSR probes. EvoSiR4 is a versatile small-molecular probe that can be employed in CaSR-related biomedical analyses where antibodies are not applicable.
PubMed: 38751613
DOI: 10.1021/acsptsci.4c00096 -
JAMA Network Open May 2024Hypoparathyroidism following thyroid surgery is a serious complication that occurs frequently when surgery is performed by low-volume thyroid surgeons without experience...
IMPORTANCE
Hypoparathyroidism following thyroid surgery is a serious complication that occurs frequently when surgery is performed by low-volume thyroid surgeons without experience in parathyroid surgery.
OBJECTIVE
To evaluate the occurrence of hypoparathyroidism following total thyroidectomy after the introduction of autofluorescence in low-volume, nonparathyroid institutions.
DESIGN, SETTING, AND PARTICIPANTS
This prospective, multicenter cohort study, with a follow-up period of up to 1 year, was conducted in Denmark at 2 low-volume nonparathyroid institutions between January 2021 and November 2023. All adult patients referred for total thyroidectomy were assessed for eligibility (n = 90). Only patients with no history of thyroid surgery were considered (n = 89). Patients who only underwent lobectomy (n = 6) or declined to participate (n = 5) were excluded. All included patients completed follow-up. The prospective cohort was compared with a historical cohort of successive patients undergoing primary total thyroidectomy from 2016 to 2020 (before autofluorescence was available).
INTERVENTION
Included patients underwent autofluorescence-guided total thyroidectomy.
MAIN OUTCOMES AND MEASURES
Rate of hypoparathyroidism. Immediate hypoparathyroidism was defined as the need for active vitamin D postoperatively, whereas permanent hypoparathyroidism was considered when there still was a need for active vitamin D 1 year after surgery.
RESULTS
Seventy-eight patients underwent autofluorescence-guided surgery (mean [SD] age, 55.6 [13.1] years; 67 [86%] female) and were compared with 89 patients in the historical cohort (mean [SD] age, 49.7 [12.8] years; 78 [88%] female). The rate of immediate hypoparathyroidism decreased from 37% (95% CI, 27%-48%) to 19% (95% CI, 11%-30%) after the introduction of autofluorescence (P = .02). Permanent hypoparathyroidism rates decreased from 32% (95% CI, 22%-42%) to 6% (95% CI, 2%-14%) (P < .001), reaching 0% at the end of the study. More parathyroid glands were identified with autofluorescence (75% [95% CI, 70%-80%] vs 61% [95% CI, 56%-66%]) (P < .001) and less parathyroid glands were inadvertently excised (4% [95% CI, 1%-11%] vs 21% [95% CI, 13%-31%]) (P = .001).
CONCLUSIONS AND RELEVANCE
In this cohort study of autofluorescence-guided thyroid surgery in low-volume, nonparathyroid institutions, the use of autofluorescence was associated with a significant decrease in both immediate and permanent hypoparathyroidism. When autofluorescence was used, hypoparathyroidism rates were comparable with those of high-volume surgeons who also perform parathyroid surgery.
Topics: Humans; Thyroidectomy; Hypoparathyroidism; Female; Male; Middle Aged; Prospective Studies; Postoperative Complications; Adult; Denmark; Optical Imaging; Aged; Surgery, Computer-Assisted
PubMed: 38748422
DOI: 10.1001/jamanetworkopen.2024.11384 -
Cureus Apr 2024Secondary hyperparathyroidism is a prevalent complication of end-stage renal disease (ESRD), arising from chronic renal insufficiency leading to disturbed calcium...
Secondary hyperparathyroidism is a prevalent complication of end-stage renal disease (ESRD), arising from chronic renal insufficiency leading to disturbed calcium metabolism. This disruption triggers hypersecretion of the parathyroid gland, characterizing the condition. Osteitis fibrosa cystica (OFC), a rare complication of untreated secondary hyperparathyroidism, results in benign resorptive bone lesions and the formation of cystic cavities within bones. Our case report describes a 46-year-old incarcerated Hispanic male with a 17-year history of end-stage renal disease and secondary hyperparathyroidism. The patient initially presented with a traumatic right elbow injury. Further diagnostic evaluation revealed an 8 cm destructive process involving the distal humerus, initially suspected as malignancy but confirmed as OFC through bone biopsy. Management involved orthopedic surgery performing an open reduction and internal fixation (ORIF) of the affected limb, with subsequent consideration for inpatient parathyroidectomy. Imaging studies, including magnetic resonance imaging (MRI) and computed tomography (CT) scans, elucidated a 6 × 5.5 cm soft tissue mass, further confirmed as a brown tumor. The case underscores the complexities of diagnosing OFC, often misinterpreted in radiologic studies, and highlights the multidisciplinary approach involving orthopedics, otolaryngology, and nephrology in managing this intricate scenario. The objective is to explore clinical manifestations and treatment challenges of OFC and secondary hyperparathyroidism triggered by trauma in end-stage renal disease, emphasizing the need for continued awareness and precise diagnostic strategies in resource-rich areas.
PubMed: 38741796
DOI: 10.7759/cureus.58208 -
Surgical Laparoscopy, Endoscopy &... Jun 2024Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is newly applied technology. Carbon nanoparticles (CNs) are novel lymph node tracers that have been...
BACKGROUND
Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is newly applied technology. Carbon nanoparticles (CNs) are novel lymph node tracers that have been widely used in China to help remove central lymph nodes (CLNs) and protect the parathyroid glands (PGs) in open thyroid cancer surgery. This study is to evaluate the effectiveness and safety of CNs in TOETVA.
MATERIALS AND METHODS
A total of 158 patients who underwent TOETVA with unilateral papillary thyroid carcinoma were enrolled in this study from March 2019 to February 2022. The participants were divided into a CNs group (n=88) and a control group (n=70), based on whether they received a intraoperative injection of CNs or not. Meanwhile, the CNs group were additionally divided into 2 subgroups, leakage subgroup (n=26) and standard subgroup (n=62). The 2 groups and subgroups were compared in terms of patient characteristics, perioperative clinical results, and postoperative outcomes.
RESULTS
All common metrics had no significant differences were found between the CNs group and the control group ( P >0.05). The standard subgroup of CNs group had advantage over the control group on PGs identification (59/62 vs. 59/70 for superior PG, 56/62 vs. 52/70 for inferior PG, P <0.05). Moreover, the standard subgroup harvested more CLNs than the control group (8.97±2.96 vs. 7.47±2.93, P <0.05). More operation time was spent on the leakage subgroup of CNs group than the control group (160.00±17.61 vs. 140.00±13.32, P <0.05). Meanwhile, the leakage subgroup had disadvantage on intraoperative hemorrhage (26.15±10.80 vs. 21.21±7.09, P <0.05) and hospital durations (4.96±0.72 vs. 4.57±0.69, P <0.05). Furthermore, the leakage group identified fewer inferior PG than the control group (7/26 vs. 52/70, P <0.05). Contrary to the standard subgroup, the CLNs of the leakage subgroup was also unsatisfactory compared with the control group (4.96±1.84 vs. 7.47±2.93, P <0.05).
CONCLUSIONS
The application of CNs suspension tracing technology has a definite effect in TOETVA. It can improve the thoroughness of lymph node dissection in the central region and enhance recognition of the PG. However, refined extracapsular anatomy is indispensable to prevent CN leakage. Leaked CNs will also be counterproductive to the operation.
Topics: Humans; Male; Female; Thyroid Cancer, Papillary; Thyroidectomy; Thyroid Neoplasms; Carbon; Nanoparticles; Natural Orifice Endoscopic Surgery; Adult; Middle Aged; Lymph Node Excision; Operative Time; Retrospective Studies; Treatment Outcome
PubMed: 38722747
DOI: 10.1097/SLE.0000000000001286 -
Gland Surgery Apr 2024Surgery is the only curative treatment strategy for parathyroid carcinoma (PC). However, the optimal extent of surgery remains uncertain, particularly regarding whether...
BACKGROUND
Surgery is the only curative treatment strategy for parathyroid carcinoma (PC). However, the optimal extent of surgery remains uncertain, particularly regarding whether routine central lymph node dissection (LND) confers a survival advantage to patients with PC. This study aimed to evaluate the prognostic value of LND in PC patients.
METHODS
Patients diagnosed with PC between 2004 and 2018 were identified in the Surveillance, Epidemiology, and End Results (SEER)-18 registries. With inclusion and exclusion criteria, a total of 338 patients were included as cohort 1 to describe the characteristics of PC, while 215 patients were selected as cohort 2 to assess the effect of LND on cancer-specific survival (CSS). Univariate and multivariate Cox proportional hazards regression models were used to identify independent risk factors associated with CSS. Propensity score matching (PSM) was performed to adjust for potential confounding variables. The prognostic value of LND was further analyzed in subgroups stratified by predictors associated with CSS.
RESULTS
The 5- and 10-year CSS were 94.4% and 87.9% respectively in cohort 1. LND failed to significantly improve CSS in the entire cohort 2 and the PSM cohort 2. Large tumor size (>40 mm) and distant metastasis were independently associated with poor CSS. Subgroup analyses revealed that LND was not significantly associated with improved CSS in patients with aggressive PC, such as those with a tumor size greater than 40 mm. Unexpectedly, LND may compromise CSS in patients with distant disease (P=0.03).
CONCLUSIONS
PC is a rare and indolent endocrine malignancy. The presence of large tumors and distant metastases are independent predictors of poor CSS. Routine central LND as part of initial surgery does not significantly improve CSS in PC patients, even for those with large tumors, lymph node metastasis, or distant disease.
PubMed: 38720673
DOI: 10.21037/gs-23-501 -
Diagnostic Cytopathology Jul 2024F-fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) has become the mainstay for staging and post-therapy surveillance of...
Fine needle aspiration diagnosis of benign oncocytic lesions of the head and neck associated with false positive F-fluorodeoxyglucose uptake on positron emission tomography scan.
INTRODUCTION
F-fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) has become the mainstay for staging and post-therapy surveillance of cancer as malignant neoplasms generally demonstrate higher FDG uptake that benign entities. However, there are certain benign lesions, most notably oncocytic tumors, that can display very high uptake and fine needle aspiration (FNA) is usually done to confirm malignancy. Therefore, it is important to recognize that benign oncocytic lesions of the head and neck may also present as FDG-avid lesions to avoid a diagnostic pitfall.
METHODS
Electronic search of institutional surgical and cytopathology archives was conducted to identify cases of benign oncocytic lesions involving the head and neck region diagnosed by FNA from January 2012 to April 2022. Chart review was used to assess whether lesions were initially discovered via PET scanning.
RESULTS
One hundred and twenty-five cases of oncocytic lesions were identified; 12 (9%) PET positive lesions were identified in the head and neck region from patients being evaluated for metastasis or for suspicion of malignancy. Cytopathology of all 12 cases demonstrated benign oncocytic lesions; eight (67%) of these cases were consistent with Warthin tumor, one (8.3%) was a benign oncocytic lesion, and one (8.3%) was consistent wit a parathyroid adenoma. Most (58%) of the PET-positive lesions were in parotid region, two from thyroid gland (17%), one from submandibular gland (8%), one from paratracheal area (8%). The PET scan SUVs ranged from 3.3 to 19.5 g mL.
CONCLUSIONS
Oncocytic lesions including Warthin tumors can result in false-positive FDG uptake on PET scans. Clinicians and cytopathologists should be aware of PET-positive benign oncocytic head and neck lesions.
Topics: Humans; Fluorodeoxyglucose F18; Biopsy, Fine-Needle; Middle Aged; Female; Male; Head and Neck Neoplasms; Aged; Adult; False Positive Reactions; Positron Emission Tomography Computed Tomography; Positron-Emission Tomography; Aged, 80 and over; Radiopharmaceuticals; Adenolymphoma
PubMed: 38712593
DOI: 10.1002/dc.25331 -
AME Case Reports 2024Coronavirus disease 2019 (COVID-19) infection has been associated with various endocrinopathies. Few literatures have reported cases of transient hypoparathyroidism in...
BACKGROUND
Coronavirus disease 2019 (COVID-19) infection has been associated with various endocrinopathies. Few literatures have reported cases of transient hypoparathyroidism in acute COVID-19 infections, or even exacerbation of hypocalcaemia in previously known hypoparathyroidism patients. The mechanism of hypocalcaemia in COVID-19 infection remains unclear.
CASE DESCRIPTION
Our patient is a young gentleman who was incidentally diagnosed with superior mesenteric artery (SMA) syndrome and symptomatic primary hypoparathyroidism while presenting with an acute COVID-19 infection. He initially presented with high-grade fever, followed by multiple episodes of vomiting and abdominal pain and subsequently hypocalcaemic symptoms such as tonic-clonic seizures and carpopedal spasms. A computed tomographic scan of his abdomen revealed a SMA syndrome while his blood investigation showed a parathyroid hormone (PTH)-dependent hypocalcaemia. His SMA syndrome was a result of severe malnourishment and improved with refeeding, but his primary hypoparathyroidism persisted despite having recovered for 6 months from the initial COVID-19 infection. There was no evidence to suggest a congenital cause of hypoparathyroidism.
CONCLUSIONS
To the best of our knowledge this is the first case report that describe this unique case of persistent primary hypoparathyroidism related to COVID-19 infection. Parathyroid gland involvement in a COVID-19 infection is rare but not impossible. Further studies are needed to determine the mechanism and extent of damage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to the parathyroid glands.
PubMed: 38711895
DOI: 10.21037/acr-23-106 -
AME Case Reports 2024Familial hypocalciuric hypercalcemia (FHH) is a hypercalcemic syndrome that is usually characterized by uncomplicated hypercalcemia and normal longevity. The inheritance...
BACKGROUND
Familial hypocalciuric hypercalcemia (FHH) is a hypercalcemic syndrome that is usually characterized by uncomplicated hypercalcemia and normal longevity. The inheritance pattern is autosomal dominant with high penetrance, and it affects both men and women equally. FHH is caused by mutations that disturb the normal functioning of the calcium-sensing receptor () gene. This causes a general lack of sensitivity to calcium, eventually leading to hypercalcemia and low calcium levels in the urine.
CASE DESCRIPTION
We report a case of a healthy 24-year-old female with longstanding hypercalcemia and a family history indicating asymptomatic hypercalcemia. The patient was also asymptomatic and had no significant past medical or surgical history. Laboratory investigations and the genetic study revealed findings suggestive of FHH subtype 1.
CONCLUSIONS
The phenotype of FHH is normal, and symptoms of hypercalcemia are usually not present. Patients with FHH and hypoparathyroidism have lower calcium clearance than controls with hypoparathyroidism. This shows that relative hypocalciuria in FHH is not caused by hyperparathyroidism. Since calcium does not appropriately suppress or affect the parathyroid glands in FHH, this means that FHH is a disorder of abnormal transport of extracellular calcium and/or response to it in at least two organs, the parathyroid gland and the kidney. It is quite similar to primary hyperparathyroidism (pHPT) biochemically hence it is important to differentiate this condition from pHPT and hypercalcemia caused by other diseases to avoid any unnecessary surgical or medical intervention.
PubMed: 38711891
DOI: 10.21037/acr-23-132